Gurpreet Dhaliwal

Renowned physicians' perceptions of expert diagnostic practice.

Purpose To further the development of a substantive theory of expert diagnostic practice, the authors explored the ways in which exceptional physicians, nominated by their peers, conceptualized their own diagnostic expertise specifically and diagnostic excellence generally. Method In this grounded theory, interview-based study, physicians at six North American research sites were nominated by their peers as exceptional diagnosticians and exceptional professionals and invited to participate in the study. A saturation sample included 34 participants, 20 exceptional diagnosticians, and 14 exceptional professionals. Using a constant comparative approach, the authors conducted one-on-one interviews with participants, transcribed the audiotapes of those interviews, and analyzed them for emergent themes. They developed a stable thematic structure and applied it to the entire data set. Results Four interconnected themes emerged that inform the community’s understanding of how physicians conceptualize expert diagnostic practice: (1) possession of extensive knowledge built through purposeful, continuous engagement in clinical practice, (2) possession of the skills to effectively gather patient stories, (3) reflective integration of that knowledge and those patient stories during diagnosis, and (4) continuous learning through clinical practice. Conclusions Exploring these results within the context of current discourses in medical education brings to the forefront two key features of physicians’ construction of diagnostic excellence: (1) the integrated nature of the medical competencies that underpin the diagnostic process and (2) the optimally adaptive nature of the diagnostic process. These findings can inform the development of practical and effective pedagogical strategies to guide trainees, clinicians, and medical educators who strive for excellence.

Examining Patient Conceptions: A Case of Metastatic Breast Cancer in an African American Male to Female Transgender Patient

An African American male to female transgender patient treated with estrogen detected a breast lump that was confirmed by her primary care provider. The patient refused mammography and 14 months later she was diagnosed with metastatic breast cancer with spinal cord compression. We used ethnographic interviews and observations to elicit the patient’s conceptions of her illness and actions. The patient identified herself as biologically male and socially female; she thought that the former protected her against breast cancer; she had fears that excision would make a breast tumor spread; and she believed injectable estrogens were less likely than oral estrogens to cause cancer. Analysis suggests dissociation between the patient’s social and biological identities, fear and fatalism around cancer screening, and legitimization of injectable hormones. This case emphasizes the importance of eliciting and interpreting a patient’s conceptions of health and illness when discordant understandings develop between patient and physician.

Educational agenda for diagnostic error reduction

Diagnostic errors are a major patient safety concern. Although the majority of diagnostic errors are partially attributable to cognitive mistakes, the most effective means of improving clinician cognition in order to achieve gains in diagnostic reliability are unclear. We propose a tripartite educational agenda for improving diagnostic performance among students, residents and practising physicians. This agenda includes strengthening the metacognitive abilities of clinicians, fostering intuitive reasoning and increasing awareness of the role of systems in the diagnostic process. The evidence supporting initiatives in each of these realms is reviewed and a course of future implementation and study is proposed. The barriers to designing and implementing this agenda are substantial and include limited evidence supporting these initiatives and the challenges of changing the practice patterns of practising physicians. Implementation will need to be accompanied by rigorous evaluation.

Preparing fourth-year medical students to teach during internship

Interns are expected to teach medical students, yet there is little formal training in medical school to prepare them for this role. To enhance the teaching skills of our graduating students we initiated a 4-hour “teaching to teach” course as part of the end of the fourth-year curriculum. Course evaluations demonstrate that students strongly support this program (overall ratings 2000 to 2005: mean=4.4 [scale 1 to 5], n=224). When 2004 course participants were surveyed during the last month of their internship, 84% “agree” or “strongly agree” with the statement: “The teaching to teach course helped prepare me for my role as a teacher during internship” (2005: mean 4.2 [scale 1 to 5], n=45, response rate 60%). A course preparing fourth-year students to teach during internship is both feasible and reproducible, with a minimal commitment of faculty and resident time. Participants identify it as an important addition to their education and as useful during internship.

Improving diagnostic reasoning to improve patient safety.

Both clinicians and patients rely on an accurate diagnostic process to identify the correct illness and craft a treatment plan. Achieving improved diagnostic accuracy also fulfills organizational fiscal, safety, and legal objectives. It is frequently assumed that clinical experience and knowledge are sufficient to improve a clinicians diagnostic ability, but studies from fields where decision making and judgment are optimized suggest that additional effort beyond daily work is required for excellence. This article reviews the cognitive psychology of diagnostic reasoning and proposes steps that clinicians and health care systems can take to improve diagnostic accuracy.

A randomized trial of hypothesis-driven vs screening neurologic examination

Objective: We hypothesized that trainees would perform better using a hypothesis-driven rather than a traditional screening approach to the neurologic examination. Methods: We randomly assigned 16 medical students to perform screening examinations of all major aspects of neurologic function or hypothesis-driven examinations focused on aspects suggested by the history. Each student examined 4 patients, 2 of whom had focal deficits. Outcomes of interest were the correct identification of patients with focal deficits, number of specific deficits detected, and examination duration. Outcomes were assessed by an investigator blinded to group assignments. The McNemar test was used to compare the sensitivity and specificity of the 2 examination methods. Results: Sensitivity was higher with hypothesis-driven examinations than with screening examinations (78% vs 56%; p = 0.046), although specificity was lower (71% vs 100%; p = 0.046). The hypothesis-driven group identified 61% of specific examination abnormalities, whereas the screening group identified 53% (p = 0.008). Median examination duration was 1 minute shorter in the hypothesis-driven group (7.0 minutes vs 8.0 minutes; p = 0.13). Conclusions: In this randomized trial comparing 2 methods of neurologic examination, a hypothesis-driven approach resulted in greater sensitivity and a trend toward faster examinations, at the cost of lower specificity, compared with the traditional screening approach. Our findings suggest that a hypothesis-driven approach may be superior when the history is concerning for an acute focal neurologic process.

A brief educational intervention in personal finance for medical residents

IntroductionAlthough medical educational debt continues to escalate, residents receive little guidance in financial planning.AimTo educate interns about long-term investment strategies.SettingUniversity-based medicine internship program.Program DescriptionAn unselected cohort of interns (n = 52; 84% of all interns) underwent a 90-minute interactive seminar on personal finance, focusing on retirement savings. Participants completed a preseminar investor literacy test to assess baseline financial knowledge. Afterward, interns rated the seminar and expressed their intention to make changes to their long-term retirement accounts. After 37 interns had attended the seminar, a survey was administered to all interns to compare actual changes to these accounts between seminar attendees and nonattendees.Measurements and Main ResultsInterns’ average score on the investor literacy test was 40%, equal to the general population. Interns strongly agreed that the seminar was valuable (average 5.0 on 5-point Likert scale). Of the 46 respondents to the account allocation survey, interns who had already attended the seminar (n = 25) were more likely than interns who had not yet attended (n = 21) to have switched their investments from low to high-yield accounts at the university hospital (64 vs 19%, P = 0.003) and to enroll in the county hospital retirement plan (64 vs 33%, P = 0.07).ConclusionsOne 90-minute seminar on personal finances leads to significant changes in allocation of tax-deferred retirement savings. We calculate that these changes can lead to substantial long-term financial benefits and suggest that programs consider automatically enrolling trainees into higher yield retirement plans.

Demystify Leadership in Order to Cultivate It

Correspondence should be addressed to Dr. Dhaliwal, San Francisco VA Medical Center, 4150 Clement St. (111), San Francisco, CA 94121; telephone: (415) 221-4810 ext. 4150; fax: (415) 750-6982; e-mail: gurpreet.dhaliwal@ucsf.edu. Graduate medical education programs need to develop physician–leaders who can address our broken and unsustainable health care system. But “leadership” suffers from a branding problem among trainees, who often equate it with official positions of authority. The essential function of a leader is to produce change. To make leadership an accessible and appealing goal for all trainees, it requires a redesigned brand as a multifaceted construct: an everyday instinct, a set of skills, a menu of options, and a professional obligation.

The Evolution of the Master Diagnostician

Patients seek answers to 3 basic questions. What (if anything) is wrong with me? Is there any treatment that might make me better? Will I recover? A physician’s ability to answer these questions requires skills as a diagnostician, therapist, and prognosticator. Excellent performance across all 3 domains separates great physicians from good ones, but among the triad, diagnosis is foundational. Without the correct diagnosis, proper therapy and accurate prognosis are rarely possible. The crucible of cost-conscious, quality-oriented, and evidence-based care lies in the mind of the diagnostician who collects clinical data, orders tests, and interprets results. If educators overlook the central role that diagnostic expertise plays in making physicians choose wisely,1 there is a real risk that diagnostic accuracy may be shuffled to the bottom of the deck in medical training, resulting in worse patient care. This Viewpoint draws inspiration from characterizations of the master diagnostician of the past, present,2,3 and future and considers the ways in which medical care has, is, and will be structured to help physicians develop and optimize this fundamental skill.

Doing What Comes Naturally

In this series, a clinician extemporaneously discusses the diagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process (italic) is interspersed throughout the discussion.